1740814904 NPI number — LIVING IN MOTION PHYSICAL THERAPY PC

Table of content: JENNIFER LYNN BENNETT GRUBE MD (NPI 1427006444)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1740814904 NPI number — LIVING IN MOTION PHYSICAL THERAPY PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LIVING IN MOTION PHYSICAL THERAPY PC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1740814904
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
465 HIGH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NORWOOD
Provider Business Mailing Address State Name:
NJ
Provider Business Mailing Address Postal Code:
07648-1237
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
347-696-5575
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
14454 SANFORD AVE APT 18
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLUSHING
Provider Business Practice Location Address State Name:
NY
Provider Business Practice Location Address Postal Code:
11355-1620
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
347-696-5575
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/26/2020

Additional Information

Authorized Official

Authorized Official Last Name:
LIM
Authorized Official First Name:
CHULBUM
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
347-696-5575

Provider Taxonomy Codes

  • Taxonomy code: 225100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 04695290 , issued by the state of ( NY ) . This identifiers is of the category "MEDICAID".




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